|Year : 2015 | Volume
| Issue : 2 | Page : 183-187
Knowledge and attitude of medical professionals towards emergency management of avulsed tooth in a teaching medical hospital, Khammam Town, South India
M Venkataramana, KVNR Pratap, T Madhavi Padma, V Siva Kalyan, ASK Bhargava, L Surya Chandra Varma
Department of Public Health Dentistry, Mamata Dental College, Khammam, Telangana, India
|Date of Web Publication||18-Jun-2015|
Department of Public Health Dentistry, Mamata Dental College, Khammam, Telangana
Source of Support: None, Conflict of Interest: None
Introduction: Injury to both the primary and permanent dentitions and their supporting structures is one of the most common problems. Avulsion of permanent tooth is one of the serious dental injuries and a prompt and correct emergency management is very important for prognosis. Studies evaluating medical professionals' knowledge about tooth avulsion and its management are rare. Aim: To assess the knowledge and attitude of medical professionals working in a teaching medical hospital in Khammam Town toward management of an avulsed tooth. Materials and Methods: A cross-sectional questionnaire-based study was conducted with a sample of 192 medical professionals including teaching staff, postgraduates, and house surgeons. A standard self-administered questionnaire was used for data collection, which was done over a period of 1-month. Chi-square test was used for data analysis with a P < 0.05 considered to be statistically significant. Results: Among the study participants 64% were aware of the meaning of avulsed tooth. About 54% of respondents preferred saline as the best storage medium to store the tooth in case professional care is not possible immediately. There was varied opinion regarding the replantation time. In this study, 41% of the participants felt 45 min as the ideal time for replantation. Conclusion: Most of the participants showed a fair knowledge on the emergency management of an avulsed tooth and their dilemma pertaining to some aspects of this procedure that can be solved by providing required awareness and knowledge.
Keywords: Avulsion, knowledge, replantation, storage medium
|How to cite this article:|
Venkataramana M, Pratap K, Padma T M, Kalyan V S, Bhargava A, Varma L S. Knowledge and attitude of medical professionals towards emergency management of avulsed tooth in a teaching medical hospital, Khammam Town, South India. J Indian Assoc Public Health Dent 2015;13:183-7
|How to cite this URL:|
Venkataramana M, Pratap K, Padma T M, Kalyan V S, Bhargava A, Varma L S. Knowledge and attitude of medical professionals towards emergency management of avulsed tooth in a teaching medical hospital, Khammam Town, South India. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2020 Jan 18];13:183-7. Available from: http://www.jiaphd.org/text.asp?2015/13/2/183/159062
| Introduction|| |
Appearance is related to facial structures, and it is recognized as the important key factor to social interactions throughout life.  Face is the most visible and vital feature to human appearance and function. Facial injuries can impair patient ability to eat, speak, interact with others, and perform other important functions. Facial injury can endanger dental health, and lead to esthetic, psychological, social, and therapeutic problems.  Among all the facial injuries, dental injuries are the most common to occur which often causes psychological as well as physical problems.  Dental injuries refer to trauma to the teeth. There are many ways in which teeth gets damaged such as chipping, breaking. Dental injury can also cause the tooth to come out of its socket, which is referred to as avulsion.
Avulsion creates a negative impact on function and esthetics due to its worse prognosis.  Avulsion occurs in 1-16% of all dental injuries.  The peak age for avulsion is between 7 and 9 years when permanent incisors are erupting, and the teeth most commonly avulsed in both primary and permanent dentition are maxillary central and lateral incisors. , The importance of anterior permanent teeth in esthetics and function cannot be underestimated as anterior teeth have a significant effect on an individual's facial profile. 
Avulsion presents a challenge with regard to its proper emergency management. The principle challenge is to maintain the vitality of periodontal cells.  Hence, immediate replantation of avulsed permanent tooth is generally accepted as treatment of choice  as replantation may successfully save the tooth and it is needed to restore esthetics and function for the patient and contribute to an improved self-image and enhanced self-esteem in children. ,
Many patients with avulsed tooth visit medical professionals due to lack of awareness or unavailability of the dentist.  Good prognosis of injured teeth largely depends on prompt and appropriate management.  To ensure proper and appropriate management, it is essential that medical professionals should have adequate knowledge and sufficient training.  Furthermore, our search of the literature revealed that only few studies by Abu-Dawoud, et al. from other countries showed 83.3% had no knowledge and only one study by Jyothi, et al. were been conducted in India assessing the knowledge and attitude of medical doctors toward tooth avulsion.
Hence, the present study was designed with the aim to assess the knowledge and attitude of medical professionals working in Khammam Town Towards management of an avulsed tooth.
| Materials and methods|| |
The present study was a cross-sectional survey with a sample of 192 medical professionals including the teaching staff, postgraduates, and house surgeons of a teaching medical hospital in Khammam Town, South India. All the participants who were willing to participate were included in the study based on convenience sampling. Ethical clearance and informed consent were obtained prior to the start of the survey.
The instrument used for the study is a standard questionnaire  designed in English language. The questionnaire consists of questions regarding the demographic data such as name, age, gender, qualification, etc., and 14 close-ended questions which were so framed that the knowledge and attitude of medical professionals could be assessed regarding the emergency management of avulsed tooth.
It is a self-administered questionnaire study. Only one investigator participated in the data collection. The questionnaires were given to participants during clinical hours when they were not attending patients and collected immediately after completion.
Data collection was done in March, 2014 over a period of 1-month using a standard questionnaire. Data collected was entered into excel sheet and Chi-square test was used for data analysis with a P < 0.05 considered to be statistically significant.
| Results|| |
A total of 192 individuals participated in the study. Among the study subjects, 71% (n = 137) were males and 29% (n = 55) were females. In the study population majority were postgraduates 42% (n = 81) followed by 32% (n = 61) and 26% (n = 50) House surgeons and teaching staff, respectively [Table 1].
|Table 1: Distribution of medical professionals by gender and designations|
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When the participants were asked about the meaning of avulsion, the majority of doctors 64% (n = 122) were aware of the meaning, followed by 33% (n = 63) of doctors who thought that it was dislodgement of fractured segment of the tooth due to any trauma, and very few of them 4% (n = 7) did not know the meaning at all. When comes to the knowledge on the management of avulsed tooth, 79% (n = 151) of the participants were unaware of it. Among those who had knowledge, majority of them 49% (n = 20) acquired information from other sources, followed by 29% (n = 12) received information during tenure of medical courses, and 17% (n = 7) and 5% (n = 2) from conferences/conventions and health talks, respectively.
About 29% (n = 56) of the participants had encountered the patients with avulsed tooth. Among those who had encountered the patients with avulsed tooth majority of them 60% (n = 115) had recommended the patients to the dentist whereas 1% (n = 1) suggested to discard the tooth.
Among the study participants 45% (n = 86) of medical professionals were unaware of time of replantation of avulsed tooth, whereas very few participants 5% (n = 9) have answered that it should be replanted within ½ h (P = 0.004). Majority of the participants 41% (n = 79) felt 45 min as the ideal time for replantation and 33% (n = 63) felt 1 h as the ideal time whereas 23% (n = 44) thought 30 min and very few 3% (n = 6) have answered it as 15 min. With regards to gender, 43.8% of the males and 34.5% of female professionals considered 45 min as the ideal time for replantation [Figure 1].
|Figure 1: Response of the participants on the ideal time for replantation by gender|
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When enquired about the knowledge of transport media, majority of the respondents 53% (n = 102) preferred saline to preserve the tooth in case professional care is not possible immediately, whereas 24% (n = 47) preferred water, 19% (n = 36) preferred patients saliva, and only very few 4% (n = 7) preferred milk as transport media (P = 0.05). Among the study participants majority, 56.2% of the male and 45.5% of female professionals preferred saline as transport medium [Figure 2].
|Figure 2: Response of the participants on the ideal transport media by gender|
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Majority of the participants 78% (n = 149) felt that the tooth should be rinsed gently under running tap water for few seconds if the tooth is dirty, whereas 6% (n = 12) would clean the tooth using a tooth brush and only 3% (n = 5) of the participants felt no need to clean the tooth because it is useless. This was found to be statistically significant (P = 0.00).
About 49% (n = 94) of the participants preferred to hold the tooth anywhere and 31% (n = 60) preferred to hold by crown and 20% (n = 38) would suggest to hold the tooth by root. Only 15% (n = 28) of the participants could differentiate the permanent tooth from a deciduous tooth. Only 34% (n = 65) of the medical professionals would care if tooth that has been knocked out was primary tooth whereas 66% (n = 127) would not care (P = 0.03).
Saliva is preferred as ideal transport media by 60% of teaching staff, 60.3% of postgraduates, and 55.7% of house surgeons [Figure 3]. Majority 90.9% of female and 83.2% of male medical professionals refer to the dentist immediately after avulsion [Figure 4].
|Figure 3: Response of the participants on the ideal transport media by designations|
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|Figure 4: Response of the participants on the course of their action if present at the site of accident by gender|
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When enquired medical professionals 50.8% of postgraduates, 45.9% of house surgeons, and 38% teaching staff 45 min as the ideal time for replantation [Figure 5]. Majority 88.5% of house surgeons followed by 86% of teaching staff and 82.7% of postgraduates refer patient to the dentist in case of avulsion of the tooth [Figure 6].
|Figure 5: Response of the participants on the ideal time for replantation by designations|
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|Figure 6: Response of the participants on the course of their action if present at the site of accident by designations|
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| Discussion|| |
Most of the participants (79%) had no prior knowledge regarding the management of avulsed tooth. This was approximately similar with the study by Abu-Dawoud et al. where 83.3% of young physicians had no knowledge on the management. Another study by Dali. M and 58.6%  on medical doctors showed that 67% of them had no knowledge regarding the emergency management. The reason might be that the medical professionals could not receive sufficient knowledge during their tenure of medical courses.
About 60% of the participants preferred to refer the patient to dentist, which is slightly higher with the results of Young et al. who reported that 32.8% of their respondents recognized the urgency of seeking professional care as soon as avulsion occurs. It was very encouraging that the respondents of the present study felt that the dentist can manage the situation better way.  Majority of the participants (53%) choose saline as the best storage medium. This is because the medical doctors felt that saline would act as the anti-bacterial agent.
Good prognosis for avulsed tooth depends on immediate replantation.  Time plays a vital role for avulsed tooth to preserve its vitality with minimal damage to periodontal cells.  In our study, only 23% doctors told that they would replant the tooth into the socket within 30 min but this figure was much lesser when compared to that obtained by Zhao and Gong where 88.5% of the participants would replant the tooth within 30 min. , The reason might be due to lack of knowledge and information regarding the same. Andersson et al.  found that 90% of teeth replanted within 30 min did not develop root resorption and prognosis would be better.
Knowledge of the most appropriate method to clean a dirty, knocked out tooth prior to replantation is very important. In the present study, (78%) participants preferred to clean the avulsed tooth under running tap water, but in the survey conducted by Halawany et al.  89.5% reported that they would rinse the tooth under running tap water without scrubbing. This shows that our respondents were unaware that they would severely decrease the chance of replantation.
Permanent teeth should be replanted or should be placed in suitable medium if immediate replantation is not possible. Deciduous teeth should not be replanted. Therefore to carry out the most suitable emergency management, it is necessary to distinguish between the two types. However, 14.58% of the participants in our study could not identify the tooth correctly whether it is primary or permanent but when similar survey carried out by Young et al.  About 70.4% of the respondents stated that they could not distinguish between primary and permanent tooth. It is therefore recommended that educational material for medical professionals should include the advice regarding the same.
Majority of the participants (66.15%) would not care if the knocked out tooth were primary. This is generally accepted because of the possibility of damaging the developing tooth bud of a permanent successor. , It is important to place more attention on the management of tooth avulsion for the medical doctors through educational campaigns in order of improving its management. Furthermore, a greater importance should be placed on avulsion of the tooth through under graduation and postgraduation medical curricula.
| Limitations|| |
The limitations of the present study are smaller sample size, which could limit its possibility to generalization of the other population.
| Recommendations|| |
A high level of awareness programs and training courses on the immediate management of tooth avulsion is obviously desirable among medical professionals which should emphasize the possible consequences following trauma so that they can at least provide the primary management at the earliest possible time before referring to the dentist.
| Conclusion|| |
Many of the participants showed a fair knowledge on the emergency management of an avulsed tooth and their dilemma pertaining to some aspects of this procedure can be solved by providing required awareness and knowledge. As medical doctors form a vital link between the patient and dentist, we need to educate them on emergency management of an avulsed tooth.
| References|| |
Nuvvula SK, Dedeepya P, Lakshmi KR. Knowledge regarding emergency management of avulsed teeth: A Survey of general dentists in Nellore, Andhra Pradesh. J Indian Assoc Public Health Dent 2011;17:560-3.
Faus-Damia M, Alegre-Domingo T, Faus-Matoses I, Faus-Matoses V, Faus-Llacer VJ. Traumatic dental injuries among school children in Valencia Spain. J Clin Exp Dent 2011;16:292-5.
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al.
Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dent Traumatol 2007;23:130-6.
Zakirulla M, Togoo RA, Yaseen SM, Al-Shehri DA, Al-Ghamdi AS, Hafed MS, et al
. Knowledge and Attitude of Saudi Arabian school teachers with regards to emergency management of Dental Trauma. Int J Clin Dent Sci 2011;2:25-9.
Halawany HS, Al Jazairy YH, Al Hussainan NS, Al Maflehi N, Jacob V, Abraham NB. Knowledge about tooth avulsion and its management among dental assistants in Riyadh, Saudi Arabia. BMC Oral Health 2014;14:46.
Jyothi KN, Venugopal P, Nanda S, Shah MK. Knowledge and Attitude of medical doctors towards emergency management of avulsed tooth - A Cross sectional survey. J Dent Sci Res 2011;2:156-67.
Dali M, Naulaka D, Rajbanshi L. Knowledge, Attitude and practice in emergency management of avulsed tooth among medical doctors in Nobel Medical College, Biratnagar, Nepal: A cross sectional survey. Int J Dent Health Sci 2014;1:3-12.
Abu-Dawoud M, Al-Enezi B, Andersson L. Knowledge of emergency management of avulsed teeth among young physicians and dentists. Dent Traumatol 2007;23:348-55.
Young C, Wong KY, Cheung LK. Emergency management of dental trauma: Knowledge of Hong Kong primary and secondary school teachers. Hong Kong Med J 2012;18:362-70.
Prasanna S, Girijan A, Narayan NL. Knowledge and attitude of primary school teachers toward tooth avulsion and dental first aid in Davangere City: A cross sectional survey. Int J Clin Pediatr Dent 2011;4:203-206.
Kaur H, Kaur S, Kaur H. Prehospital emergency management of avulsed permanent teeth: Knowledge and attitude of school teachers. Indian J Dent Res 2012;23:556.
Kaur M, Gupta K, Goyal R, Chaudhary N. Knowledge and Attitude of school teachers towards tooth avulsion in rural and urban areas. Int J Sci Study 2014;1:17-20.
Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ, et al.
International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.
Traebert J, Traiano ML, Armênio R, Barbieri DB, de Lacerda JT, Marcenes W. Knowledge of lay people and dentists in emergency management of dental trauma. Dent Traumatol 2009;25:277-83.
Choi D, Badner VM, Yeroshalmi F, Margulis KS, Dougherty NJ, Kreiner-Litt G. Dental trauma management by New York City school nurses. J Dent Child (Chic) 2012;79:74-8.
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